‘The pause’ allows for moment of silence after a patient death

When a patient dies during resuscitative measures, clinicians don't always stop and
reflect. “Generally, they walk away…. The body is left in whatever
condition it was in, and the auxiliary staff is left to help clean up and prepare
the body for family to come in,” said Jonathan Bartels, RN, a palliative care
liaison at the University of Virginia Medical Center in Charlottesville.

There could be many reasons for leaving the room, he noted. “As a hospitalist,
you've done everything you can for that patient and were unsuccessful. Often, there
might be people leaving in frustration because they didn't necessarily gain the outcome
that they were seeking, so they turn away from the body,” said Mr. Bartels,
who worked for 11 years as an ED trauma nurse.

But there is an alternative. Mr. Bartels recently spoke with ACP Hospitalist about “the pause,” a moment of silence after a patient's death that
he began initiating 2 or 3 years ago. He originally started the practice after a young
woman's death in the ED, and since then, it has expanded to other units in the hospital.

Q: What is the pause?

A: The pause is simply just a means of honoring a patient after they pass away, and it's
done in such a way that you can have a multicultural group of people in the same room
focused on 1 point, which is the patient who's passed away. It's honoring the patient
as a group, but doing it in silence as individuals in their own personalized way,
whether that be in prayer or…in thinking positive thoughts or just recognizing
the moment and the real importance of that particular moment.

Q: Where did this idea come from?

A: I had seen a chaplain stop a team and do a prayer. When she had done it, the stopping
was the awesome part for me. The prayer part didn't necessarily [resonate] because
I didn't share the same tradition that this person was coming from…. I didn't
think it was a very big deal because I thought, this is what everyone does, right?
We take a moment, we honor that person. But I soon found out that it's not what everyone
automatically falls to, and to ask for it and call out for it gives them permission
or invites them to try it out. In terms of its inception, I think we've paused as
human beings for a long time. But our society, what goes on, and the speed of our
medicine, the speed of technology, we don't take time to pause enough.

Q: Who is generally involved in the pause?

A: Anyone who's involved in trying to resuscitate the patient, so respiratory therapists,
physicians, pharmacists, techs, family, social work. Whoever's in there and whoever's
making the effort to try and bring them back. I've also used this process in ICUs
after doing terminal extubations on patients, so it doesn't only have to happen after
resuscitative attempts.

Q: Who initiates a pause?

A: It can happen from anyone. As this has progressed, oftentimes I've had the chief surgical
physician call out for a pause. That's when I knew I had something, when the trauma
surgeon looked at me and said, “Do your thing.” It's also being done
by ER physicians, it's being done by nurses, and it's being done by technicians in
the room. It's anyone who's emboldened enough to really take that step to ask for
it.

Q: What do you say to initiate it?

A: Generally, what I say is, “Before we leave the room, could we just take a moment
to stop as a group and honor this person that was in the bed? Before they came here,
they had a life, and they had family. They were loved, and they loved other people.
[Let's] take that time to recognize that right now, and also take the time to honor
and recognize the efforts we put in to try to save them, and do that in such a way
in silence so that we can each have our own voice.”

Q: How long does it last?

A: For surgeons, I can only do about 30 or 45 seconds, but hospitalists and medical doctors
let me do it for a minute.

Q: When does it typically occur?

A: Ideally, I think the moment after resuscitative measures have been attempted; that's
what the original practice did. I've seen it done now where sometimes they'll have
family presence during resuscitations, so they'll call the family in and then call
for the pause. Generally, we try to do it before we leave the room, but I have seen
it done where that wasn't possible, and I actually saw it done in a hallway.

Q: What kind of reaction to the pause have you seen from clinicians and family members?

A: I think from a family standpoint, it exemplifies that we care and that we're not just
treating a body in a bed. In this act, we're honoring a human. When a family member
loses someone—I know this from my own experience—my world stops. And
when we do this pause, what we do is actually participate in the stopping that this
family is experiencing at their loss, even for a brief moment.

Staff [reactions] can be varied. You can have staff that really enjoy doing it. Oftentimes,
that's what I hear about 80% to 90% [of the time]. But then, there are those individuals
who, I think, may have underlying issues from years of experiencing this type of situation
that may not have dealt with it as well. Even 30 seconds of stopping and honoring
causes them distress, and they can't participate. That's 1 reaction, where they say,
“I can't do this, or I'll break down.” Other people just deal with it
differently, and it might not be the thing they want to do, or they suppress their
feelings and just want to continue to move on, and that's how they cope. And by all
means, they're not forced to do it.

Q: What's the difference between pausing and not pausing?

A: As a clinician, it allows me to put down the situation I was just in and put that
away, so that I can step out of the room and then take care of the next person or
the next situation that I'm walking into. It allows for closure.

Q: How has the pause expanded beyond your personal practice?

A: It started to take off in the emergency room, and people started to repeat it and
replicate it and do it themselves…. I ended up publishing an article about
it, but in the meantime, people from other units started to hear about what they do
in the emergency room, and they started to replicate it across the hospital. Then
other hospitals and people from other facilities read the article in the [February
2014] Critical Care Nurse journal, and they started contacting me and implementing programs similar to it. And
it's something they're encouraged to do as not a policy, but just as a means of practice.

Q: What advice would you give a clinician who wants to implement a pause?

A: I always stress that you really shouldn't impose your own religious views in this
practice. You should allow the silence to be what it is because everyone does things
in their own way. This allows everyone to be both an individual and then practice
in a group.

Q: Can this concept expand beyond the hospital?

A: My other focus is EMS and first responders, paramedics and firemen. It can be done
anywhere. I think that this pause is not the end-all be-all, but it's just one means
of trying to take care of ourselves. And I think that's really what we need to do
as health care providers. [It adds only] a minute and a half.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.